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II-6-6-7. COR 16 Request for SSA-1696 from Alleged Representative

	SOCIAL SECURITY ADMINISTRATION _____________________________________________________________
	Refer to: TAHB [SSN] [XSSN]	Office of Hearings and Appeals 5107 Leesburg Pike Falls Church, VA 22041-3255]

[Representative's First Name, Middle Initial and Last Name]
[Address]
[City, State Zip]

Dear [Mr./Ms. [Representative's Last Name]]:

Re: [Claimant's Name]

Our records do not show that the claimant has appointed a representative. Therefore, we cannot disclose any information about this case without the claimant's consent.

[If claimant acknowledges alleged representative, but acceptance of appointment is required, replace above with:]

The claimant states that [he/she] has appointed you as a representative. However, our records do not show that you have agreed to represent the claimant.

What You Must Do

We have enclosed a Form SSA-1696. This is the form used for the claimant to appoint a representative and for the representative to accept appointment.

If the claimant has appointed you as the representative, please have both sections of this form completed and return the file copy to the Appeals Council.

Our address and FAX number are:

Put the Social Security Number shown at the top of this letter on your request.

If you send us anything by fax, do not send duplicates by mail. That may delay processing your claim.

What Happens Next

If we do not hear from you within 30 days, we will proceed with our action and will notify the claimant.

If You Have Any Questions

If you have any questions, you may call or write the Appeals Council. Our telephone number and address are shown at the top of this letter. If you do call, please have this notice with you.

Enclosures:
[SSA-1696]
Self-addressed envelope

cc:
[Claimant's Name]

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